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Infectious Diarrhea

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Table of Contents


Diarrhea is a subject matter which most of us will be familiar with at some point in our lives, whether we travel or invade the wilderness. It is a common ailment that rarely gets discussed in any detail, mostly because it is self-limited in nature. This means that our own body's defenses are usually capable of warding off the many different types of agents of infection that are known to be responsible for this condition. Diarrhea is perhaps sometimes hard to define, but it has been said that "you know it when you see it." For this reason, we at Survive Outdoors believe that a photo would not be appropriate, and will leave it to your imagination.

It is surprising in this day and age that we do not have a great understanding of all the causes of most individuals' diarrhea. If you look at any textbook, you will see a very long list of causative agents (mostly infectious in nature). Whenever you hear a physician say that your condition is "probably due to a virus," this should be a red flag that medicine has not done enough research or has not been able to develop enough accuracy in determining the exact cause of the problem. It is true that viruses cause many of man's ailments including infectious diarrhea. However more recent studies would indicate that bacteria are a very common source of diarrhea. For the most part as mentioned, it is a self-limited disease process, but on occasion can certainly be inconvenient and frequently incapacitating, and on a rare occasion, potentially deadly.

Infectious diarrhea is contracted by food, beverage or waterborne pathogens, either viruses, bacteria or parasites. Many travelers to developing countries are familiar with "traveler's diarrhea." This is a form of infectious diarrhea caused by bacteria that does not seem to bother the intestines of individuals who live in these countries. (Interestingly, when these individuals travel to our country, they get a similar form of traveler's diarrhea.) It seems our intestines become accustomed to certain types of bacteria and when new species are introduced by food or beverages we consume, we are at risk for developing traveler's diarrhea.

Outdoor enthusiasts are perhaps more familiar with Giardia, which is a protozoa microorganism. This is commonly found in most North American fresh bodies of water. It can cause severe cramping and abdominal pains with foul smelling, watery stools.

Prevention is the first step in limiting one's exposure to any infectious agent, including those that cause infectious diarrhea. Sound food preparation and handling are key. For the outdoors enthusiast, this means making sure that you have adequate potable water with you for preparing food, drinking and personal hygiene, including brushing your teeth. For limited excursions, carrying your own water may be reasonable, but for longer excursions, it is important to have some type of water purification system available to you. Traditionally, iodine tablets have been used and are highly effective, but often leave a bad taste and are not indicated for individuals with certain medical conditions such as thyroid disease or pregnancy. Heating water to be used for personal use works well, but you need to have a fuel source. If there is not a weight or space concern, this method is best. You need only bring the water to a boil (even at altitude) for microorganisms to be killed. It is not necessary to "boil" the water for a few minutes. This is simply a waste of fuel. Good hand washing and use of anti-microbial detergent or soap should always be employed when cleaning utensils, as well as your hands. If you are traveling to an exotic locale or developing country, prevention is still important. Although hotels, etc. may have all appearances as their counterparts in the U.S., realize that the water sources that are used may be questionable or poorly monitored, and that the individuals who work in these institutions may not practice good personal hygiene. The cook or waiter who makes your fine meal served to you in the dining room may go home to a residence that has no toilet or running water. So, it is good practice to eat food that is hot, boiled, peeled or cooked. Use only bottled water and avoid ice or food items that have been simply washed (salads, fruits).

What to do if prevention is ineffective? The range of treatment options depends on the source. For those with limited but inconvenient diarrhea, loperamide is available over-the-counter and very effective for most individuals. It should not be used for prevention, but only for treatment of bothersome and symptomatic diarrhea. For those on prolonged excursions where medical help won't be routinely available, the appropriate selection of antibiotics (and other anti-microbial medicines) I believe are a necessary part of your medical kit. You should discuss with your medical provider medications you should have with you and when and how they are to be used in the event of a significant intestinal infection.

When should you seek medical help? Certainly when dehydration is a possibility because of frequent diarrhea, or when fever, abdominal pain or bloody stools are noted. These symptoms herald a potentially serious infection that needs to be evaluated and treated emergently. One should not wait and see if it resolves on its own or with symptomatic treatment.

What to do if medical help is not immediately available? Trying to keep the patient hydrated even in the presence of vomiting can be highly effective. Re-hydration solutions are available, but any liquid given in small amounts frequently may help stave off dehydration, even when vomiting is a prominent feature. Additional anti-emetic (anti-vomiting) medication should be part of your medical kit for those departing on longer trips. If you have been provided appropriate anti-microbial medications, using these at the first sign of worrisome symptoms can be curative.

Being prepared is the hallmark of a wise traveler. Having a good plan in advance and bringing with you the necessary supplies to both prevent, and if necessary treat diarrheal illness will hopefully contribute to a spiritually moving experience as opposed to an intestinally moving one (pun intended.) Feel free to send us any questions you may have.

Cryptosporidium Parvum

Cryptosporidium is a protozoa that also causes infectious diarrhea, and is commonly found in contaminated water. It is characterized by severe watery diarrhea that may be accompanied by a low-grade fever. In general, it is a self-limiting illness, and if left untreated usually lasts 2-4 days. Outbreaks are frequently seen in daycare centers. Common symptoms include cramping, nausea and weight loss and usually develop 4-6 days post ingestion, although symptoms may develop as long as 10 days afterwards. Bloody stools are uncommon.

Cryptosporidium is spread mainly by oral contact with contaminated objects, by drinking polluted water, eating unwashed vegetables and swimming in contaminated water and getting small amounts of water in your mouth.

It is a myth that you cannot get cryptosporidium from chlorinated pools, although it is less common. Filtering or boiling water when camping is extremely effective in neutralizing cryptosporidium.

Cryptosporidium Parvum Treatment

Healthcare Provider - Medical Treatment
Cryptosporidium is a protozoa responsible for many cases of diarrhea every year. It is commonly spread by different animals, specifically cows, deer, domesticated cats and dogs. It is important to note that for purification purposes, Cryptosporidium is for the most part resistant to iodine purification. It can be identified through acid-fast staining, which confirms the diagnosis.

Treatment as per the Sanford Guide to Anti-microbial Therapy, 2004, recommends trying Paromomycin plus Azithromycin. Recommended dose is one gram of Paromomycin, 2x/day, and 600 mg. of Azithromycin once/day. It does appear that Alinia may be very effective against Cryptosporidium. The Sanford Guide is recommending 500 mg. to a gram 2x/day for 2 weeks, and the pediatric dose is 100-200 mg. 2x/day for 3 days.

Campylobacter Jejuni

Campylobacter is an infectious bacteria causing severe diarrhea. Bloody diarrhea is commonly seen in infected individuals, as in individuals infected with E. Coli, but unlike diarrhea resulting from cryptosporidium and Giardia contamination, as discussed earlier. Nausea and vomiting are also common symptoms. The main cause of Campylobacter is ingesting infected poultry and eggs. Un-pasteurized milk is another source of Campylobacter. Therefore, it is important if bringing along poultry, other forms of meat, and eggs when camping, that it is thoroughly rinsed and adequately cooled. As heat does kill this organism, if is important to thoroughly cook meat. Also, make sure you wash your hands frequently and thoroughly during and after handling food products.

Infected individuals should drink plenty of fluids so that they do not get dehydrated. Medications such as Erythromycin or other antibiotics called Fluoroquinolones may shorten the duration of the illness. Most individuals recover completely without any treatment in approximately 5-7 days, but it may take up to two weeks to resolve. For further information, go to www.cdc.gov and look under Campylobacter.

Campylobacter Jejuni Treatment

Healthcare Provider - Medical Treatment
Campylobacter Jejuni is a gram-negative bacillus that is responsible for many cases of diarrhea every year. Treatment as recommended by the Sanford Guide to Anti-microbial Therapy, 2004: Ciprofloxin, 500 mg., one, 3x/day for 5 days or Azithromycin, 500 mg./day for 3 days has been found to be very effective. You can also use Erythromycin, 1-2 grams/day in four divided doses. It is also important to note that Campylobacter is usually self-limiting and the infected individual will become asymptomatic in 5-7 days. However, these medications will eradicate it more quickly. Side-note: In Thailand, as recently as last year, resistance to Quinolones when used to treat Campylobacter has been noted.

Giardia Lamblia

Giardia is the most common parasite in the United States and Canada. Incubation period is approximately 3 weeks. The patient usually presents with malodorous diarrhea, which can be explosive and watery. It may last for 3-4 days. History provided may provide important clues regarding exposure, such as a history of camping, drinking well water, travelers return from endemic areas, etc. Giardia is more commonly being seen in daycare settings.

Boiling kills the parasite instantly. You do not have to boil the water for 5-10 minutes. As soon as the water comes to boil, the parasite is killed.

Labs for Ova and parasites (O & P) can produce falsely negative results, and testing is very expensive. Survive Outdoors recommends to the medical provider to hold off on these until the patient presents with any of the following:

  1. Patient with bloody stools.
  2. Patient who handles food as part of their job.
  3. Patient with a high fever.
  4. Patient with immuno-compromise.
  5. Patient with history of antibiotic use as you have to be concerned about C-Dificile.

Giardia Symptoms

Incubation period is 1-3 weeks after ingestion of contaminated water, although in general, symptoms do not occur before 2-3 weeks. Symptoms include diarrhea, increased gas, stomach cramps and fatigue. Bloody and watery stools, often seen as a result of infection from the bacteria such as E. Coli, are uncommon. Nausea and increased abdominal noiseare also commonly seen.

Survive Outdoors frequently instructs individuals that if they are lost in the woods, to go ahead and drink the water rather than risk death from dehydration. Once found, medical treatment for Giardia should be sought, although symptoms most likely will not have begun to manifest themselves.

Giardia Treatment

Healthcare Provider - Medical Treatment
Metrodiazole (Flagyl) is an excellent medication. Fluid intake should be increased slowly; for example, a tablespoon of Gatorade or other liquids every ten to fifteen minutes. Given the loss of fluid from diarrhea, great care must be taken that affected individuals do not become dehydrated. There are great water filters available on the market that can filter out the protozoa Giardia, and therefore excellent to take with when camping or fishing. Survive Outdoors highly recommends these in order to avoid contact with the Giardia organism.

Metronidazole, 250 mg., 3x/day for 5 days, or 2 grams at bedtime for 3 days, as recommended in the Sanford Guide to Anti-microbial Therapy, 2004. For years, Metronidazole was not approved for children. Nitazoxanide (Alinia) has been very effective in children. The dose is 1 tsp. for ages 12-47 months, or 2 tsp. For ages 4-11 years old. This is given 2x/day with food for 3 days.

Studies have found that Alinia is not only effective with Giardia, but very effective with Cryptosporidium, 84% effective with all the protozoans and 95% effective with Helminths. This author has used this medication on two occasions, and has had very good success with it.

Alinia (Nitazoxanide)

Alinia (Nitazoxanide) is a relatively new anti-parasitic specifically in the treatment of children diagnosed with Giardia or Cryptosporidium. Both are water-borne bacteria. This is a relatively safe anti-parasitic. As per the Alinia website, 7.8% of patients did experience some abdominal pain, while only 2% experienced diarrhea, 1% vomiting, and 1% headache. Recommended age is 1-11 years. Benefits: It does have a pleasant strawberry flavor, and it does not have to be taken for as long as Flagyl. The current treatment guidelines are 1 tsp. 2x/day for 3 days. It is advised to take this medication with food. For more information, please go to www.alinia.com.

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